Provider Demographics
NPI:1417127028
Name:DAVIS AND WINE DENTAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:DAVIS AND WINE DENTAL ASSOCIATES, LLC
Other - Org Name:TERMOTTO & DAVIS DENTAL PRACTICE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:H
Authorized Official - Last Name:WINE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:843-705-9551
Mailing Address - Street 1:4 OKATIE CENTER BLVD SOUTH
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909
Mailing Address - Country:US
Mailing Address - Phone:843-705-9551
Mailing Address - Fax:843-705-9552
Practice Address - Street 1:4 OKATIE CENTER BLVD SOUTH
Practice Address - Street 2:SUITE 103
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909
Practice Address - Country:US
Practice Address - Phone:843-705-9551
Practice Address - Fax:843-705-9552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80911223G0001X
SC17171223G0001X
SC45831223G0001X
GA1223G0001X, 1223P0300X, 1223P0700X
SC1223G0001X, 1223P0300X, 1223P0700X
SC41821223P0700X
GADN0132981223P0700X
SC46761223P0700X
GADN0152711223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty